Provider Demographics
NPI:1326054271
Name:BENNETT, STEFANIE MARIE (LAC)
Entity Type:Individual
Prefix:MRS
First Name:STEFANIE
Middle Name:MARIE
Last Name:BENNETT
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:STEFANIE
Other - Middle Name:
Other - Last Name:KOCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAC
Mailing Address - Street 1:18627 BROOKHURST #507
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-5603
Mailing Address - Country:US
Mailing Address - Phone:714-962-5031
Mailing Address - Fax:714-962-5039
Practice Address - Street 1:18046 MAGNOLIA
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-5603
Practice Address - Country:US
Practice Address - Phone:714-962-5031
Practice Address - Fax:714-962-5039
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC9255171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAC9255OtherACUPUNCTURE LICENSE